FAQ Category: Knee

The shin bone, called the tibia is one of the bones that is most commonly broken. Because of this, doctors and surgeons have a lot of experience in treating broken tibias. One thing they know is that if the tibia is broken in the lower third, the part of the shin bone closest to the foot, it is harder to treat and keep straight than if it happens higher on the bone.

Although your daughter had surgery on the leg, there are many variables that can affect if the surgery is completely successful or not. These include the type of hardware (screws, nails, and/or plates) that are used, the amount of damage to the bone and the surrounding tissue, and if there is an infection.

With today’s improved surgical technology, patients have the option of bilateral total knee replacement (TKR) at the same time. This can be done by one surgical team doing both knees (first one, then the other) in the same operation. Or there can be two surgical teams working on both knees at the same time.

There are some concerns to consider. The overall rate of complications is greater for bilateral TKR compared with unilateral or staged bilateral procedures. Staged bilateral refers to having both knees replaced but they are done one at a time with a certain time interval (weeks to months) between procedures. The number of patients sent to the intensive care unit (ICU) is higher with simultaneous TKRs. The number of days they stay in ICU is also greater for bilateral versus unilateral TKR.

The risk of cardiac complications in patients having bilateral TKRs is four times the risk for those having one knee done. The risk of heart problems increases with age. There are several reasons for this. Heart disease is more common as we age. And the heart and lungs have less reserve capacity to respond to the stress of surgery.

On the plus side, there is less anesthesia used with bilateral simultaneous TKRs. Improved surgical technique means less blood loss. And rehab has to be done for both knees anyway. So the total length of time in recovery is less. There are fewer days of pain and a shorter hospital stay with fewer costs.

When making the decision to replace both knees at the same time, there are many factors to consider. Your overall health and the presence of any other medical problems or conditions must be weighed in the decision-making process.

It has been suggested by many researchers based on results of studies that bilateral knee replacements are best done in high-volume hospitals by an experienced surgeon. Usually such facilities also have adequate intensive care units to care for patients who need close monitoring. Hospital staffing of nurses, operating room tech support, and experience of surgeon and staff are all important points.

A frank discussion with your surgeon and your physical therapist will help direct your decision. Don’t hesitate to bring up your family’s concerns. You will benefit from the experiences of other patients and families who have already had this procedure done.

With today’s improved anesthesia and postoperative care, patients have the option of bilateral total knee replacement (TKR) at the same time. This can be done by one surgical team doing both knees (first one, then the other) in the same operation. Or there can be two surgical teams working on both knees at the same time.

An alternative approach is to have a staged bilateral procedure. Staged bilateral refers to having both knees replaced. But they are done one at a time with a certain time interval (weeks to months) between procedures.

However it’s done, it has been suggested by many researchers based on results of studies that bilateral knee replacements are best done in high-volume hospitals by an experienced surgeon. Usually such facilities also have adequate intensive care units to care for patients who need close monitoring.

Each surgeon has his or her own techniques and postoperative management measures. Steps can be taken during and after surgery to prevent complications. For example, the surgeon tries to avoid making too large of a hole in the shaft of the bone to insert the implant.

Improved surgical techniques are helping to reduce the number of fat emboli that cause postoperative problems. When the bone is cut open, a glob of fat from inside the bone marrow can enter the blood stream. The embolism can travel to the heart or brain causing serious problems such as death, heart attack, or stroke. Suctioning of the hole where the implant will go helps cut down on the number of fat emboli that occur.

Newer techniques to minimize blood loss, reduce stress on the heart and lungs, and prevent other complications have made this kind of surgery possible.

At first, treatment for a PCL injury focuses on decreasing pain and swelling in the knee. Rest and mild pain medications, such as acetaminophen (Tylenol), can help decrease these symptoms. You may need to use a long-leg brace and crutches at first to limit pain. Most patients are given the okay to put a normal amount of weight down while walking.

Less severe PCL tears are usually treated with a progressive rehabilitation program. Athletes involved in high-demand sports activities may require a special knee brace before returning to play. These braces are designed to replace knee stability when the PCL doesn’t function properly. They help keep the knee from giving way during moderate activity.

Most patients receive physical therapy treatments after a PCL injury. Therapists treat swelling and pain with the use of ice, electrical stimulation, and rest periods with your leg supported in elevation.

Exercises are used to help you regain normal movement of joints and muscles. Range-of-motion exercises should be started right away with the goal of helping you swiftly regain full movement in your knee. This includes the use of a stationary bike, gentle stretching, and careful pressure applied to the knee by the therapist.

Exercises are also given to improve the strength of the quadriceps muscles on the front of the thigh. As your symptoms ease and strength improves, you will be guided in specialized exercises to improve knee stability.

If the PCL alone is injured, nonsurgical treatment may be all that is necessary. When other structures in the knee are injured, patients generally do better having surgery within a few weeks after the injury. Long-term studies show that without reconstructive surgery, over time, knee instability and joint degeneration develop.

The main goal of surgery is to keep the tibia from moving too far backwards under the femur and to get the knee functioning normally again. New studies also suggest the need to restore medial-lateral (side-to-side) and rotational stability, too.

Most surgeons now favor reconstruction of the PCL using a piece of tendon or ligament to replace the torn PCL. It’s important that the surgeon identify all areas of the joint that have been damaged. For example, PCL injuries are often accompanied by damage to the posterolateral corner. And studies show that repairing the PCL without fixing the corner results in a failed surgery.

Posterior refers to the back side of the knee.Lateral is along the outside edge of the joint. There are five basic structures that make up the posterolateral corner. These include two muscles: the lateral head of the gastrocnemius (calf) and the popliteus. Three ligaments are also involved: the popliteofibular ligament, the lateral collateral ligament (LCL), and the arcuate-fabellofibular ligament complex.

You will probably be involved in a progressive rehabilitation program for four to six months after surgery to ensure the best result from your PCL reconstruction. In the first six weeks following surgery, expect to see the physical therapist two to three times a week. If your surgery and rehabilitation go as planned, you may only need to do a home program and see your therapist every few weeks over the four to six month period.

Many people are familiar with anterior cruciate ligament (ACL) tears. But inside the knee joint there are two important ligaments. The ACL criss-crosses with the posterior cruciate ligament (PCL). And PCL injuries account for up to one-third of all knee injuries.

The PCLs main job is to keep the tibia (lower leg bone) from sliding backwards under the femur (thigh bone). A second function of the PCL is to restrain the tibia from rotating outward too far.

It is possible to test for PCL injury using clinical exams, stress X-rays, and MRIs. But there are problems with each of these tests. The biggest problem is that there could be a combined PCL tear and damage to the posterolateral corner that goes undetected. If the PCL tear is repaired surgically but the posterolateral corner isn’t reconstructed, then joint laxity (looseness) can lead to another injury later.

Posterior refers to the back side of the knee.Lateral is along the outside edge of the joint. There are five basic structures that make up the posterolateral corner. These include two muscles: the lateral head of the gastrocnemius (calf) and the popliteus. Three ligaments are also involved: the popliteofibular ligament, the lateral collateral ligament (LCL), and the arcuate-fabellofibular ligament complex.

The surgeon’s exam may be limited by patient discomfort and muscle splinting and guarding during the exam. With the patient completely relaxed under anesthesia, an accurate exam can be done. Once the full extent of the damage is determined, then the appropriate surgical repair or reconstruction can be done for the best result.

Knee injuries are fairly common for males and females in sports that require jumping and/or pivoting. These include basketball, soccer, volleyball, football, and handball. Ligaments in and around the knee such as the medial collateral ligament (MCL) and the anterior cruciate ligament (ACL) are most commonly injured.

It’s clear that females have a greater risk of these types of injuries compared with males. The reasons for this aren’t entirely clear. But biomechanics, anatomy, and neuromuscular control are all part of the picture.

Efforts are being made to study this problem. Researchers are very close to finding an exercise program that might reduce ACL injuries during practice and games. A special program called the Prevent Injury and Enhance Performance (PEP) Program shows great promise among college-aged female soccer players.

The PEP program consists of a series of strengthening, stretching, and agility exercises. ACL injuries are reduced when the PEP program is performed three times a week as a warm-up before practice. When the research is complete, this program will likely find its way into the hands of coaches of all levels of female athletes at risk for ACL injuries.

You may be referring to an exercise program that was first developed by the Santa Monica Orthopedic and Sports Medicine Research Foundation. They called it the Prevent Injury and Enhance Performance (PEP) Program. The program consists of 19 parts that can be done by the whole team in less than 30 minutes. It was studied and found to be successful in the late 1990s.

A more recent, up-to-date study was just published. National Collegiate Athletic Association (NCAA) Division I soccer teams from around the country were included. There were 61 teams with over 1400 athletes involved. The goal was to see if this alternative warm-up program could reduce the number of ACL injuries. The specific focus was on noncontact injuries among female athletes.

The exercise groups used the PEP program for 12 weeks during the regular soccer season. A training video was used to demonstrate all the exercises. The teams had to complete the PEP program at least 12 times to be included in the data analysis. Most teams reported completing an average of 25 exercise sessions.

This type of neuromuscular program takes several weeks to improve strength, balance, and proprioception. Athletes reported that the program got easier as time went by. After six to 12 training sessions, the exercises were no longer perceived as physically challenging. And best of all, there was a significant reduction in new and repeat ACL injuries in exercise group.

There were some limitations in the study. So more research is needed. For example, the program worked for college-level female soccer players. But what about the high school female athlete? Or female athletes in other sports such as basketball or volleyball? And future studies need to look at subgroups and see if age or experience is a factor.

For optimal healing, tissue must be protected and shouldn’t be overloaded. This is very important after autologous chondrocyte implantation (ACI). Ideally, you would see a physical therapist before surgery to practice muscle contractions and weight-bearing loads. This is helpful since you will be progressing after surgery through a gradual increase in how much weight you can put on the joint.

And it can be difficult to gauge how much weight is acceptable. There could be many other factors affecting the success of accurate weight-bearing. The role of pain, swelling, and muscle weakness may affect your ability to stand and move easily without putting too much weight on the joint.

Mental state and physical fragility after surgery must also be taken into consideration. It does seem to help to use a forearm crutch (sometimes two crutches) at lower levels of allowed weight-bearing. The added weight is offloaded onto the arms.

You can expect a five-to-eight week period of time during which you will gradually increase the amount of load until you are weight bearing fully on that leg. Muscle strengthening and training to improve motor control will be started during that time. Special exercises to restore normal joint proprioception (sense of position) will also be included.

You are asking a very good question. There are commercially available products such as limb-load monitors, pressure insoles, and force monitoring platforms. But these are expensive and usually only available in a research facility or physical therapy department.

Many therapists don’t even have these materials. They often use a simple bathroom scale to give patients a feel for weight load. This is not a perfect solution, but it’s a start. Studies show that even with practice, patients aren’t able to replicate the required force within five per cent accuracy.

Researchers have found that lower levels of weight-bearing are more difficult to gauge than higher levels. So for example, it’s easier to stay on target when you are allowed to put 80 per cent of your body weight compared with only 20 per cent.

Depending on the surgery, extreme accuracy may not be important. For example, weight-bearing on an ankle fusion with instrumentation (plates and/or screws) may be able to tolerate more weight than a cartilage implantation. The fixation devices used in the fusion will help hold the joint in place while bone healing takes place. Cartilage implantation is more delicate. Too much load can disrupt the healing cells leading to graft failure.

You may have a condition called bipartite patella. Sometimes it’s also called patella bipartite. As you have described, the patella or kneecap is made up of two bones instead of a single bone. Normally, the two bones would fuse together during adolescence. But in patella bipartite, they remain as two separate bones.

About two to three per cent of the general population have this condition. It remains silent until direct trauma or repetitive (overuse) injury cause pain and/or swelling. The cartilage between the two pieces of bone has a limited ability to heal. There may be a limited blood supply to this area. And constant pull on the patella from the quadriceps tendon causes a traction force. These factors added together can result in limited healing.

The only way to know for sure if there has been a change is to have an X-ray taken. CT scans or bone scans are useful when a fracture is suspected but doesn’t show up on the X-rays. An MRI may be ordered to look at the condition of articular cartilage at the patellar-fragment interface. The lack of bone marrow edema helps rule out a bone fracture.

Bipartite patella is a congenital condition (present at birth) that occurs when the patella (kneecap) is made of two bones (instead of a single bone). Normally, the two bones would fuse together as you grow. But in patella bipartite, they remain as two separate bones.

Most of the time, this condition is silent. The person doesn’t even know he or she has it. But direct trauma to the kneecap or repetitive injury (overuse) can trigger painful symptoms. The usual advice given to athletes with this condition is to rest and stop playing until the symptoms go away.

It’s understandable that if you are trying to get on the tennis team, this isn’t very helpful advice. You may benefit from antiinflammatory medications and a four-to-six week course of physical therapy. The therapist will help you find ways to modify your activity. Exercises to balance function of the quadriceps muscle may help.

In cases where the pain is severe enough to limit daily activities (or for athletes with an upcoming season), surgery may be indicated. There are several approaches available to the surgeon. The exact procedure used depends on the size and condition of the bone fragment.

If the fragment is small enough, it could be just removed. Large fragments can be taken out, too, but there is a chance that arthritis will develop later. The surgeon may also release the vastus lateralis. These are the tendon slips from the quadriceps muscle that attach along the outside edge of the patella. Too much pull too often from this tendon can cause pain. Symptoms may be relieved by releasing the tendon from the fragment and/or from the entire patella.

The patella, or kneecap, can be a source of pain when it fails to function properly. Alignment or overuse problems of the patella can lead to pain, weakness, and swelling of the patellofemoral joint.

The patellofemoral joint is where the patella moves up and down over the femur (thigh bone). This problem is called patellofemoral pain syndrome (PFPS). PFPS is most common among athletes and military recruits (soldiers).

Following patients with PFPS over the years to see what happens to their painful symptoms helps us know what is the natural history of the condition. There aren’t very many long-term studies of the natural history of PFPS. But what has been done suggests that the majority of PFPS sufferers continue to have pain throughout the rest of their lives.

Most are still able to join in on sports activities as desired. But less than one-quarter of the patients studied were ever pain free. About 25 per cent reported continued pain even with activity modification.

The long-term results of PFPS are good with regular exercise for the quadriceps muscle. A specific training program can be set up for your daughter by a physical therapist. A 10-minute daily program can help her maintain a pain free status. Most of the time, strengthening and stretching exercises are enough to manage the problem and prevent the need for surgery.

The patella, or kneecap, can be a source of knee pain when it fails to function properly. Alignment or overuse problems of the patella can produce pain, weakness, and swelling of the knee joint.

Several different problems can affect the patella and the groove it slides through over the femur (thigh bone). Patellofemoral pain syndrome (PFPS) is one of these problems. PFPS can affect people of all ages but is most common among young athletes. Physicians in sports medicine clinics report it accounts for up to 10 per cent of all visits.

There are several possible reasons why PFPS develops. The first is overloading the patellofemoral joint. Heavy competition in sports has been a potential cause of this overload. And overload combined with malalignment of the quadriceps tendon as it pulls on the patella during extension of the knee is another probable cause of PFPS.

Both of these factors lead to dysfunction of the extensor (quadriceps) mechanism. If one part of this four-part muscle pulls unevenly, the patella doesn’t track up and down correctly over the knee joint. That’s when pain and swelling start to develop. Alignment or overuse problems of the patella can also lead to wear and tear of the cartilage behind the patella. This can cause another problem called chondromalacia.

Studies show that exercise works well to manage PFPS. A progressive program of strengthening and stretching helps balance the muscle pull and knee alignment. Most often, it’s best to have an individual program to address each athlete’s unique anatomy and biomechanics. An athletic trainer or physical therapist can help you with this.

For those girls who are out of the game, a rehab program is advised. This is to prevent the same problem from occurring when they do resume sports activity. It only takes 10 to 20 minutes daily to effectively manage PFPS.

Most athletes are already spending a great deal of time engaged in exercise and activity. This isn’t a significant burden on their time. And the benefits pay off in the end with pain free sports participation.

Osteochondral lesions of the knee occur in adolescent athletes with some regularity. A shearing force across the joint causes the cartilage to pull away through its full thickness. Planting the foot on the ground and twisting over the knee is the main mechanism of injury. The force of it may pull away a piece of the underlying bone with the cartilage.

This is a fairly common injury among adolescent athletes. The frequency of this problem does not mean we have the perfect treatment worked out yet. Until recently, the fragments were just removed. That type of treatment at least reduces the pain and stops the knee from giving way or locking up on you.

But it may not be ideal. Leaving a gaping hole in the cartilage sets the patient up for a potential problem years down the road. The defect fills in with a mixture of fibrous cartilage. Since the injury is located on the weight-bearing surface, constant pressure over the area causes further breakdown. Eventually, a degenerative arthritis develops.

Pain, swelling, and knee locking are common symptoms with osteochondral fractures. Leaving the injury untreated isn’t usually an option. Today, scientists are studying better ways to treat the problem.

One possibility is internal fixation of the fragments. Tiny rods made of polyglycolic acid are placed between the torn fragment(s) and the bone. The rods are small bioabsorbable rod-shaped implants. During the healing process, the polyglycolic acid is absorbed and replaced by living tissue.

Only short-term and medium-term results have been reported. But the outcomes look promising. Patients have normal looking X-rays and MRIs as the cartilage heals. There may not even be any thinning of the cartilage when viewed on closer inspection.

Cartilage repair technology is still being developed. A special fibrin glue is also being used in some experiments. This is not available everywhere. Eventually, it may be possible to repair the torn fragments and restore full function of the knee.

Just as you already know, it’s clear that knee injuries are problematic for female athletes. In particular, anterior cruciate ligament (ACL) tears are common. Rehab and recovery from such an injury can put a player on the bench for an entire season.

Scientists at human movement and biomechanic research laboratories continue to study this problem. They start with cadavers (knees preserved after death for study) and examine the effect of load, torque, and alignment on movement of the knee.

Then they study the spring, laxity, and stiffness qualities of human male versus female knees under different conditions. They know that there are differences in alignment. These are important factors. But they also know that there’s a sex-difference in how stiff the joint is.

This kind of stiffness isn’t what we refer to as we get older. This quality is the response of the joint to loads, especially twisting or side-to-side force. The muscles around the knee tighten up to prevent joint displacement and thereby prevent ligament damage.

Men seem to have a stable level of stiffness. No matter how much load is applied (small to large), the joint doesn’t give. But women seem to have variable stiffness. Low loads respond with less stiffness than higher loads. This is okay when the load increases gradually. But it becomes a problem when there’s a sudden shift in load. The knee stiffness doesn’t increase quickly enough to prevent injury.

How to respond to this in practice remains to be seen. As more information about differences between male and female athletes is collected, practical suggestions may be easier to make.

New information about patellofemoral pain syndrome (PFPS) has come to light in the last 10 years. But scientists are still scratching their heads over the issue of why one person gets it and another (with similar anatomical structure) doesn’t.

There is one theory that may explain why the same load causes patellofemoral pain for one person but not another. It’s called the envelope of function or the envelope of load acceptance theory.

This theory says that loads transmitted across the knee vary for a wide range of reasons. The person’s center of gravity may be slightly different from someone else’s. The center of gravity changes with each position and movement of the knee. The rate at which the load is applied to the joint may make a difference. Then there’s the angle of joint flexion and rotation to consider.

Different activities and different levels of physical condition can also affect the patellofemoral joint’s load envelope. And an injury may change the load acceptance causing pain with activities that never hurt before.

More study is needed to sort out these kinds of issues. It’s especially important because variances may make a difference in treatment. Rehab for individuals with PFPS is tailored for each individual person and sport.

A Baker’s cyst can cause a pain pattern of this type. But so can patellofemoral pain syndrome (PFPS). And it’s possible to have both a Baker’s cyst and PFPS. An orthopedic surgeon can examine you and determine the cause of your symptoms.

A Baker’s cyst is a benign cyst behind the knee. It is named for a surgeon from the late 1800s. Dr. Baker was the first one to describe this problem. The cyst is a sac of synovial fluid that has leaked out of the joint. It is considered benign because it doesn’t spread or cause death. But it can be very painful and limit joint motion. Diagnosis is confirmed by ultrasound and/or magnetic resonance imaging (MRI).

Patellofemoral pain syndrome (PFPS) refers to pain around and under the patella (knee cap). Males and females of all ages from teens on up can be plagued by this problem. Athletes are especially affected.

But the cause of the problem still remains a mystery of sorts. We know that an increased Q-angle is part of the problem. An increased Q-angle means the patella is being pulled laterally (away from the other leg). This alters the way the patella tracks up and down over the femur. The result is increased stress on the patellofemoral joint.

You didn’t mention your age or athletic/sports participation. Most anterior cruciate ligament (ACL) tears occur in young athletes. Early repair is often suggested for ACL injuries, especially full-thickness tears in athletes. Surgery is also advised when there are other injuries in the area as well.

Mild injuries can often be successfully restored with a three to six month rehab program. Athletes must be very consistent in following their program. Compliance will help them avoid surgery and return to sports participation on time.

Many patients report satisfactory, good, or even excellent results after this surgery. There can be a few problems. For example, many patients who receive a bone-patellar tendon-bone graft have persistent knee pain when kneeling.

Degenerative joint changes are seen on X-ray in over one-third of the cases. Changes such as narrowing of the joint space and bone spurs around the joints may be more likely in older patients who are overweight.

Researchers are still trying to find out which patients are most likely to have an excellent result and who might have a poor result. If they can identify factors that point to a less than satisfactory result, patients can be given other treatment options. Or surgeons can begin to look for ways to improve the results of surgery.

Since no one can predict results with 100 per cent accuracy, no guarantees are made.

Joint laxity or looseness can be a difficult problem to balance with surgery. And this is especially true for patients who are already hypermobile. Hypermobile joints have excess motion.

If the joint isn’t unstable, then the joint laxity may not be a problem. But if it feels like your knee is giving out unexpectedly or with certain activities, then the instability must be addressed.

In some cases, the positioning of the graft used in the reconstruction of the ACL is the main cause of this problem. Good positioning and good alignment are needed for control of knee stability.

If this was not achieved during surgery, then rehab may help you recover your function. And if rehab is unsuccessful in restoring normal strength, proprioception (joint sense of position), and kinematics (joint movement), then revision surgery may be needed.

Talk with your surgeon about your observations and concerns. Find out what are your options before assuming this is your final result.

Researchers are just beginning to identify specific training programs that might help reduce the number of anterior cruciate ligament (ACL) injuries in women. We may not be able to change the alignment factors that contribute to this problem. But we are finding ways to alter muscle recruitment, motor control, and stiffness of the knee in response to changes in load and torque.

The result may be to prevent soft tissues from yielding too much under physical stress in women. It’s not clear yet whether it’s a matter of adding more repetitions or higher resistance to the traditional leg exercises performed.

It may be more helpful to learn how to recruit more muscle fibers faster when engaging in certain types of physical movements. Sudden shifts in weight, pivot shifts, or landing a jump are examples of common movement patterns that result in ACL injury.

Physical therapists are especially interested in finding neuromuscular strategies to use for controlling motions that could cause an injury. Actions that prepare and activate select muscles can be trained. This includes using muscles (such as the hamstrings muscle) at the right time with the right amount of force during weight bearing activities.

More information will be published on this topic in the near future. We will keep you posted on the latest.